Bright Futures Previsit Questionnaire
2 to 5 Day (First Week) Visit
For us to provide you and your baby with the best possible health care, we would like to know how things are going.
Please answer all of the questions. Thank you.
What would you like to talk about today?
Do you have any concerns, questions, or problems that you would like to discuss today?
We are interested in answering your questions. Please check off the boxes for the topics you would like to discuss the most today.
How You Are Feeling
q Your health
Getting Used to Your Baby
q How you are doing with your baby q Calming your baby
q How your baby sleeps q Placing baby on back to sleep
Feeding Your Baby
q Gaining weight q How your baby shows if he/she is hungry or full q Drinking enough
q Jaundice (skin is yellow) q Burping q Breastfeeding q Formula
Safety q Car safety seat
Baby Care
q When to call the doctor’s office q Taking your baby’s temperature q Not getting sick
q Emergency situations q Leaving the house q Skin care q Sunburns
q Feeling sad
q Family stress
q Cigarette smoke
q Unwanted advice
q Starting a daily routine
q Crib safety
q Where your baby sleeps
q Water heater temperature
q Hand washing
Questions About Your Baby
Have any of your baby’s relatives developed new medical problems since your last visit? If yes, please describe:
q Yes
q No
q Unsure
q Yes
q No
q Unsure
Vision
Do you have concerns about how your child sees?
Does your child have any special health care needs?
q No
q Yes, describe:
Other than your baby’s birth, have there been any major changes in your family lately?
q Move q Job change q Separation q Divorce q Death in the family q Any other changes? Describe:
Over the past 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things q Not at all q Several days q More than half the days
2. Feeling down, depressed, or hopeless
q Not at all q Several days q More than half the days
q Nearly every day
q Nearly every day
Adapted with permission from “Efficient Identification of Adults with Depression and Dementia,” September 15, 2004, American Family Physician. Copyright © 2004 American Academy of Family Physicians. All Rights Reserved.
Does your child live with anyone who uses tobacco or spend time in any place where people smoke?
q No
q Yes
Your Growing and Developing Baby
Do you have specific concerns about how your baby is growing, learning, or acting?
Check off each of the tasks that your baby is able to do.
q Eats well
q Turns and calms to your voice q No
q Yes, describe:
q Follows your face
q Can suck, swallow, and breathe easily
The recommendations in this publication do not indicate an
exclusive course of treatment or serve as a standard of medical
care. Variations, taking into account individual circumstances,
may be appropriate. Original document included as part of
Bright Futures Tool and Resource Kit. Copyright © 2010
American Academy of Pediatrics. All Rights Reserved. The
American Academy of Pediatrics does not review or endorse
any modifications made to this document and in no event shall
the AAP be liable for any such changes.
PAGE 1 OF 1
ACCOMPANIED BY/INFORMANT
PREFERRED LANGUAGE
DRUG ALLERGIES
Name
DATE/TIME
ID NUMBER
CURRENT MEDICATIONS
WEIGHT (%)
LENGTH (%)
TEMPERATURE
WEIGHT FOR LENGTH (%) HEAD CIRC (%)
BIRTH DATE
AGE
M
F
See growth chart.
History
H
O
S
P
I
T
A
L
Physical Examination
Term or
weeks Blood type: Maternal
Birth weight
Infant
Direct Coombs
Discharge weight
Bilirubin screening None
Newborn hearing screening Transcutaneous bilirubin
Done & NL Serum bilirubin
Hep B (maternal): Pos Neg
Hep B vaccine
/
/
Concerns and questions
None
Addressed (see other side)
Follow-up on previous concerns
None
Medication Record reviewed and updated
Child has special health care needs
Unk
Addressed (see other side)
= NL
Bright Futures Priority
Additional Systems
HEAD/FONTANELLE
GENERAL APPEARANCE
EYES (red reflex/strabismus/appears to see)
EARS/APPEARS TO HEAR
HEART
NOSE
FEMORAL PULSES
MOUTH AND THROAT
ABDOMEN (umbilical cord, vessels) LUNGS
SKIN (rashes, jaundice)
GENITALIA
NEUROLOGIC (tone, symmetry, state regulation)
Male/Testes down
MUSCULOSKELETAL (torticollis)
Female
HIPS
EXTREMITIES
BACK
Abnormal findings and comments
Previsit Questionnaire reviewed
Social/Family History
Assessment
See Initial History Questionnaire.
Family situation
Well child
Parent adjustment to new child
Maternal depression
Y
N
Reaction of siblings to new child
Work plans
Anticipatory Guidance
Child care plans
Discussed and/or handout given
Review of Systems
See Initial History Questionnaire and Problem List.
Changes since last visit
Nutrition:
Breast milk
Hours between feeding
Problems with breastfeeding
Formula
Source of water
Elimination: NL
Sleep:
Minutes per feeding
Feedings per 24 hours
Ounces per feeding
Vitamins/Fluoride
NL
Development (if not reviewed in Previsit Questionnaire)
SOCIAL-EMOTIONAL
COMMUNICATIVE
PHYSICAL DEVELOPMENT
wEats well wTurns and calms to your voice wCan suck, swallow, and
COGNITIVE breathe easily
wFollows your face
NUTRITIONAL ADEQUACY
SAFETY
wBreastfeeding (vitamin D supplement) wCar safety seat
wIron-fortified formula (if not breastfed) wSmoke-free
wNo solid foods environment
wNo honey wNo shaking
PARENTAL WELL-BEING wBurns
wBaby blues Water heater
wAccept help wSmoke detectors
wSleep when baby sleeps wCrib safety
wUnwanted advice
Plan
Immunizations (See Vaccine Administration Record.)
Laboratory/Screening results
Referral to
NL
Behavior:
NEWBORN TRANSITION
wBack to sleep
wDaily routines
wCalming techniques
NEWBORN CARE
wEmergency preparedness plan
wFrequent hand washing wAvoid direct sun exposure wExpect 6–8 wet diapers/day Follow-up/Next visit
See other side
Print Name
Signature
PROVIDER 1
PROVIDER 2
HE0471
well child/2
to 5 days (first week)
This American Academy of Pediatrics Visit Documentation Form is consistent with
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as
a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
Copyright © 2010 American Academy of Pediatrics. All rights reserved. No part of this publication may
be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
HE0471
9-208/1208
Bright Futures Parent Handout
2 to 5 Day (First Week) Visit
NUTRITIONAL ADEQUACY
• Feed only breast milk or iron-fortified
formula, no water, in the first 6 months.
• Feed when your baby is hungry.
• Puts hand to mouth
• Sucks or roots
• Fussing
• End feeding when you see your baby is full.
• Turns away
• Closes mouth
• Relaxes hands
If Breastfeeding
• Breastfeed 8–12 times per day.
• Make sure your baby has 6–8 wet diapers
a day.
• Avoid foods you are allergic to.
• Wait until your baby is 4–6 weeks old
before using a pacifier.
• A breastfeeding specialist can give you
information and support on how to position
your baby to make you more comfortable.
• WIC has nursing supplies for mothers who
breastfeed.
If Formula Feeding
• Offer your baby 2 oz every 2–3 hours,
more if still hungry.
Getting Used to Your Baby
• Comfort your baby.
• Gently touch baby’s head.
• Rocking baby.
• Start routines for bathing, feeding, sleeping,
and playing daily.
• Help wake your baby for feedings by
• Patting
• Changing diaper
• Undressing
• Put your baby to sleep on his or her back.
• In a crib, in your room, not in your bed.
• In a crib that meets current safety
standards, with no drop-side rail and
NEWBORN TRANSITION
• Use a rectal thermometer, not an ear
thermometer.
• Check for fever, which is a rectal temperature
of 100.4°F/38.0°C or higher.
• In babies 3 months and younger, fevers
are serious. Call us if your baby has a
temperature of 100.4°F/38.0°C or higher.
• Take a first aid and infant CPR class.
• Have a list of phone numbers for
emergencies.
• Have everyone who touches the baby wash
their hands first.
• Wash your hands often.
• Avoid crowds.
• Keep your baby out of the sun; use
sunscreen only if there is no shade.
• Know that babies get many rashes from 4–8
weeks of age. Call us if you are worried.
slats no more than 2 3/8 inches apart.
Find more information on the Consumer
Product Safety Commission Web site at
www.cpsc.gov.
• If your crib has a drop-side rail, keep it up
and locked at all times. Contact the crib
company to see if there is a device to keep
the drop-side rail from falling down.
• Keep soft objects and loose bedding such
as comforters, pillows, bumper pads, and
toys out of the crib. Safety
SAFETY
Feeding Your Baby
• Hold your baby so you can look at each
other while feeding
• Do not prop the bottle.
• Give your baby a pacifier when sleeping.
Baby Care
NEWBORN CARE
• Call us for help if you feel sad, blue, or
overwhelmed for more than a few days.
• Try to sleep or rest when your baby sleeps.
• Take help from family and friends.
• Give your other children small, safe ways to
help you with the baby.
• Spend special time alone with each child.
• Keep up family routines.
• If you are offered advice that you do not want
or do not agree with, smile, say thanks, and
change the subject.
NEWBORN TRANSITION
PARENTAL WELL-BEING
How You Are Feeling
NUTRITION
Here are some suggestions from Bright Futures experts that may be of value to your family.
• The car safety seat should be rear-facing in
the back seat in all vehicles.
• Your baby should never be in a seat with a
passenger air bag.
• Keep your car and home smoke free.
• Keep your baby safe from hot water and hot drinks.
• Do not drink hot liquids while holding your
baby.
• Make sure your water heater is set at lower
than 120°F.
• Test your baby’s bathwater with your wrist.
• Always wear a seat belt and never drink and drive.
What to Expect at Your
Baby’s 1 Month Visit
We will talk about
• Any concerns you have about your baby
• Feeding your baby and watching him or her
grow
• How your baby is doing with your whole
family
• Your health and recovery
• Your plans to go back to school or work
• Caring for and protecting your baby
• Safety at home and in the car
The recommendations in this publication do not indicate an
exclusive course of treatment or serve as a standard of medical
care. Variations, taking into account individual circumstances,
may be appropriate. Original document included as part of
Bright Futures Tool and Resource Kit. Copyright © 2010
American Academy of Pediatrics, Updated 10/11. All Rights
Reserved. The American Academy of Pediatrics does not
review or endorse any modifications made to this document
and in no event shall the AAP be liable for any such changes.
PAGE 1 OF 1